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Advantage AVF-1 Schedule of Benefits
Other Restorative Services Schedule
Limitations and Exclusions
ADA
CODE |
|
Procedure |
|
Member
Pays |
 |
|
|
|
|
| D2910 |
|
RECEMENT INLAY |
|
$35 |
| D2920 |
|
RECEMENT CROWN |
|
$36 |
| D2930 |
|
PREFAB STAINLESS STEEL CROWN-PRIM TOOTH |
|
$98 |
| D2931 |
|
PREFAB STAINLESS STEEL CROWN-PERM TOOTH |
|
$111 |
| D2932 |
|
PREFABRICATED RESIN CROWN-PER TOOTH |
|
$121 |
| D2940 |
|
SEDATIVE FILLING |
|
$15 |
| D2950 |
|
CORE BUILDUP, INCLUDING ANY PINS |
|
$94 |
| D2951 |
|
PIN RETENTION/PER TOOTH |
|
$20 |
| D2952 |
|
CAST POST & CORE IN ADD TO CROWN |
|
$143 |
| D2954 |
|
PREFAB POST & CORE IN ADD TO CROWN |
|
$118 |
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Note:
All procedures listed might not be performed by the Participating General Dentist you
select. The co-payments shown apply to those Participating General Dentists who do
perform those services. Therefore, you are encouraged to discuss the availability of the
scheduled services with your Participating General Dentist. Procedures not listed on this
schedule of benefits, that are performed by the Participating General Dentist, will be
charged at that Participating General Dentist's usual and customary fee less 20%.
Specialist Services
Should you need a specialist (i.e. Endodontist, Oral Surgeon, Orthodontist, Periodontist,
Prosthodontist, Pediatric Dentist), you may be referred by your Participating General
Dentist. Co-payment percentage amounts are applicable when treatment is performed by
a Participating Specialist. Procedures not listed on this schedule of benefits, that are
performed by a Participating Specialist, will be charged at that Participating Specialist's
usual and customary fee less 20%.
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